Provider Demographics
NPI:1043348881
Name:DIVINE HAVEN ASSISTED LIVING HOME
Entity Type:Organization
Organization Name:DIVINE HAVEN ASSISTED LIVING HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JUDDY
Authorized Official - Middle Name:M
Authorized Official - Last Name:CATALAN
Authorized Official - Suffix:
Authorized Official - Credentials:CNA
Authorized Official - Phone:907-317-5080
Mailing Address - Street 1:1509 N HEATHER MEADOWS LOOP
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99507-3866
Mailing Address - Country:US
Mailing Address - Phone:907-317-5080
Mailing Address - Fax:907-334-8057
Practice Address - Street 1:1961 NORENE ST
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-3447
Practice Address - Country:US
Practice Address - Phone:907-317-5080
Practice Address - Fax:907-334-8057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK100475310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKRL2862Medicaid